Transcript medical emergencies in dentistry - principles

Medical Emergencies in a
Special Care Setting
Prof. Mark Greenwood MDS, PhD, FDS, MB
ChB, FRCS, FRCS(OMFS), FHEA
Newcastle University
BDA CDS GROUP YORKSHIRE AND THE
HUMBER DIVISION, JUNE 2010
PREVENTION!
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Attitude and environment
Usually a clue in the history
Airway protection
Drills – roles, training, contact numbers
Do not work alone
IN A SPECIAL CARE SETTING
• Particular issues could include access,
patient movement, pre-existing conditions
• Potential for increased “pressure” from
carers
IN A SPECIAL CARE SETTING
• The principles of management are
essentially the same but may require
common sense modifications
THE ABCDE APPROACH
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure
AIRWAY
• Finger sweep
• Suction
• Head tilt/Chin lift
Head Tilt/Chin Lift
AIRWAY
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Finger sweep
Suction
Head tilt/Chin lift
Jaw thrust- injury or flexion deformity
BREATHING
Look, listen and feel
CIRCULATION
Central pulse e.g. carotid for the
competent/experienced practitioner – no
longer includes some dental practitioners
DISABILITY
Neurological (conscious status) e.g. Post
head injury/seizure
A lertness
V ocal stimuli response
P ain response
U nresponsive
EXPOSURE
For examination of rash/application
of defibrillator paddles (AED)
AED
DRUGS FOR EMERGENCY
DRUG BOX
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Adrenaline (Epinephrine) 1 in 1000
Aspirin (300mg)
Glucagon (1mg) (Glucose)
GTN tabs/sprays
Oxygen
Salbutamol inhaler
Midazolam buccal liquid or Midazolam injection
solution via buccal or nasal route (10mg)
POSSIBLE ROUTES OF DRUG
ADMINISTRATION
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Oral
Sublingual
Subcutaneous
Intramuscular
Inhalation
Rectal
Intravenous
IN DENTISTRY
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Oral
Sublingual
Subcutaneous
Intramuscular
Inhalation
Rectal!
Intravenous only if experienced
Deltoid
COLLAPSE OF UNKNOWN
CAUSE
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Lie patient flat, raise legs – most recover
Maintain airway, give oxygen
Check breathing - agonal gasps
If not breathing/abnormal breathing (no pulse) =
cardiac arrest
• No “signs of life”
• If normal breathing give sc/im glucagon 1mg
• Get help at an early stage
CARDIAC ARREST
• Main cause arrhythmia (VF)
• AED
REMEMBER RATIOS OF CPR
• No “rescue breaths”
• 30 compressions to 2 ventilations in adults
• Importance of early defibrillation
CPR IN PREGNANCY
• Left lateral position
SPECIFIC MEDICAL
EMERGENCIES in Dentistry
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Uncommon – including the simple faint,
occur once every 3 to 4 years per dentist
VASO-VAGAL SYNCOPE
• Commonest
• Lie flat, raise legs
ANAPHYLAXIS –
SIGNS AND SYMPTOMS
• Paraesthesia, flushing, facial swelling
• Generalised itching – hands and feet
• Bronchospasm and laryngospasm
(wheezing and breathing difficulty)
• Rapid weak pulse together with fall in
blood pressure
ANAPHYLAXIS –
MANAGEMENT
• ADRENALINE! (Epinephrine)
• 0.5ml (500 micrograms) 1 in 1000 solution
IM repeated after 5 minutes if no clinical
improvement
ADRENALINE (EPINEPHRINE)
• Alpha adrenergic action leads to
vasoconstriction increasing myocardial
and cerebral perfusion
ADRENALINE (EPINEPHRINE)
• Reverses peripheral vasodilatation and
reduces oedema
• Beta receptor activity dilates the airway,
increases the force of myocardial
contraction
• Beta activity suppresses histamine and
leukotriene release
ADRENALINE (EPINEPHRINE)
• Adverse effects are extremely rare when
appropriate doses are given
intramuscularly
ANAPHYLAXIS –
MANAGEMENT
• ADRENALINE! (Epinephrine)
• 0.5ml (500 micrograms) 1 in 1000 solution
IM repeated after 5 minutes if no clinical
improvement
• Lie flat, maintain airway, supplemental
oxygen
ANAPHYLAXIS MANAGEMENT
• Adrenaline is indicated when there are
signs of stridor, wheeze, respiratory
distress or clinical signs of shock
ANAPHYLAXIS MANAGEMENT
• Adrenaline is indicated when there are
signs of stridor, wheeze, respiratory
distress or clinical signs of shock
• The U.K. Resuscitation Council has said
that in the past, adrenaline has been
under used
THE ROLE OF CHLORPHENAMINE
(Chlorpheniramine)
AND HYDROCORTISONE
• Still used in the treatment of anaphylaxis
by “First Medical Responders”
THE ROLE OF
HYDROCORTISONE
The U.K. Resuscitation Council
(www.Resus.org.uk) recommend the use
of corticosteroids for all severe
anaphylactic reactions
PREFERRED SITE FOR
ADRENALINE INJECTION
An EpiPen
OTHER CONSIDERATIONS
• Resuscitation Council recommends doses
of adrenaline should be halved in patients
on beta blockers, tricyclics and
Monoamine Oxidase Inhibitors
ANAPHYLAXIS
• The wheezing can be helped by giving
inhaled salbutamol
“PANIC ATTACKS”
• Sometimes mistaken for anaphylaxis
• Anxiety driven
“PANIC ATTACKS”
• Signs and symptoms:
– Anxiety
– Weak, dizzy, light-headed
– Paraesthesias
– Palpitations
– Carpo-pedal spasms
• An “anxiety rash” could be confused for
the rash in anaphylaxis
CARPAL SPASM
MANAGEMENT
• Rebreathing exhaled air
• Worth having handy a paper bag!
ASTHMA
• Most attacks will respond to 2 puffs of the
patients beta2 – adrenoceptor stimulant
inhaler
• If no rapid response, repeat
• Administer oxygen
• Repeat inhaler – every 10 minutes
SPACER DEVICE
CHEST PAIN, ANGINA,
MYOCARDIAL INFARCTION
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Diagnosis of the problem
A,B,C – supplemental oxygen
Use the GTN spray
Aspirin should be given (300mg) in MI
• Entonox is helpful
MYOCARDIAL INFARCTION
• If aspirin has been given, the hospital
MUST BE INFORMED
EPILEPSY
• Medication should only be given if
convulsive seizures are prolonged or
last 5 minutes or more or are repeated
rapidly
EPILEPSY
• 10mg buccal Midazolam
• In prolonged or recurrent seizures,
midazolam intranasally – single dose of
200 micrograms per kilogram
• In children, rectal diazepam
HYPOGLYCAEMIA –
SYMPTOMS AND SIGNS
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Shaking/trembling
Sweating
“Pins and Needles” in lips and tongue
Hunger
Slurring of speech
Confusion
Change of behaviour
• Unconsciousness
HYPOGLYCAEMIA MANAGEMENT
• Glucagon 1mg IM/SC
• Once regains consciousness, oral glucose
INHALED FOREIGN BODY
• Prevention!
• Allow them to cough vigorously
INHALED FOREIGN BODY
• Ask “Are you choking”?!
CHOKING - MILD
• Patient answers “YES”!
• Victim is able to cough and breathe
CHOKING - SEVERE
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Unable to speak
Unable to breathe
Wheezy
Attempts at coughing are silent
Unconsciousness
ADRENAL CRISIS
• Signs and symptoms
– Loss of consciousness
– Rapid, weak or impalpable pulse
– Blood pressure falls rapidly
ADRENAL CRISIS TREATMENT
• Lay patient flat and raise their legs
• Clear airway and administer oxygen
ADRENAL CRISIS –
TREATMENT
• 200mg Hydrocortisone I.V.
• I.V. fluids
ADRENAL CRISIS TREATMENT
• Do not discharge!
DEVELOPMENTS IN MEDICAL
EMERGENCY MANAGEMENT
• Rationalisation of the Drug Box contents
• Practical delivery routes for drugs
• Resuscitation Guidelines particularly the
AED
USEFUL REFERENCE
• Medical Emergencies and Resuscitation
Standards for Clinical Practice and
Training for Dental Practitioners and
Dental Care Professionals in General
Dental Practice – A statement from the
Resuscitation Council (UK) July 2006.
Revised May 2008.
CONCLUSIONS
• The use of emergency drugs is safe –
when the diagnosis is correct!
• The drug kit should be checked regularly
to ensure that it is up to date
• In a special care setting, the best
approach is to stick to basic principles